med surge 2 unit 3 practice q's
A patient is ordered desmopressin (DDAVP) for the treatment of diabetes insipidus. What therapeutic response does the nurse anticipate the patient will experience? A decrease in blood pressure A decrease in blood glucose levels A decrease in urine output A decrease in appetite
A decrease in urine output
A patient had a total hip replacement. What recommended leg position should the nurse ensure is maintained to prevent prosthesis dislocation? Abduction Adduction Flexion Internal rotation
Abduction
Before discharge, what should a nurse instruct a client with Addison's disease to do when exposed to periods of stress? Administer hydrocortisone I.M. Drink 8 oz of fluids. Perform capillary blood glucose monitoring four times daily. Continue to take his usual dose of hydrocortisone.
Administer hydrocortisone I.M.
A client with severe hypoparathyroidism is experiencing tetany. What medication, prescribed by the physician for emergency use, will the nurse administer to correct the deficit? Sodium bicarbonate Fludrocortisone Calcium gluconate Methylprednisolone
Calcium gluconate
After undergoing a thyroidectomy, a client develops hypocalcemia and tetany. Which electrolyte should the nurse anticipate administering? Calcium gluconate Potassium chloride Sodium bicarbonate Sodium phosphorus
Calcium gluconate
Which cleansing solution is the most effective for use in completing pin site care? Betadine Chlorhexidine Hydrogen peroxide Alcohol
Chlorhexidine
A client was climbing a ladder, slipped on a rung, and fell on the right side of the chest. X-ray studies reveal three rib fractures, and the client reports pain with inspiration. What is the anticipated treatment for this client? Chest strapping Mechanical ventilation Coughing and deep breathing with pillow splinting Thoracentesis
Coughing and deep breathing with pillow splinting
A client with a fractured fibula has an external fixator device applied. Which interventions to care for this device will the nurse add to the client's plan of care? Select all that apply. Examine pin insertion sites daily Cover sharp fixator pins with caps Elevate the extremity to heart level Tighten loose pins on the device during pin care Monitor neurovascular status every 2 to 4 hours
Cover sharp fixator pins with caps Elevate the extremity to heart level Monitor neurovascular status every 2 to 4 hours
Hypophysectomy is the treatment of choice for which endocrine disorder? Acromegaly Cushing syndrome Hyperthyroidism Pheochromocytoma
Cushing syndrome
The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) Decreased sensory function Excruciating pain Loss of motion Capillary refill less than 3 seconds 2+ peripheral pulses in the affected distal pulse
Decreased sensory function Excruciating pain Loss of motion
Colles fracture occurs in which area? Elbow Humeral shaft Clavicle Distal radius
Distal radius
The nurse is completing the admission assessment on a 13 year old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms will the nurse expect to find? Fever and crepitus. Rales and hives. Dyspnea and wheezing. Normal chest shape and eupnea.
Dyspnea and wheezing.
A nurse is evaluating the diagnostic study data of a client with suspected cystic fibrosis (CF). Which of the following test results is associated with a diagnosis of cystic fibrosis? Elevated sweat chloride concentration Presence of protein in the urine Positive phenylketonuria Decreased tidal volume
Elevated sweat chloride concentration
A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse? Ensure that a large tourniquet is in the room. Document the receiving report from the transferring nurse. Delegate the gathering of enough pillows for proper positioning and comfort. Review the physician's orders for type and frequency of pain medication.
Ensure that a large tourniquet is in the room.
Which intervention would the nurse implement with the client in skeletal traction? Select all that apply. Apply 8-pound weight to the rope. Ensure the pins or wires are covered with caps. Remove foam boot and inspect skin daily. Position trapeze within the client's reach. Instruct the client on isometric exercises for immobilized extremity.
Ensure the pins or wires are covered with caps. Position trapeze within the client's reach. Instruct the client on isometric exercises for immobilized extremity.
In which grade of COPD is the forced expiratory volume in 1 second (FEV1) greater than 80% predicted? I II III IV
I
What is histamine, a mediator that supports the inflammatory process in asthma, secreted by? Eosinophils Lymphocytes Mast cells Neutrophils
Mast cells
Which term refers to an injury to ligaments and other soft tissues surrounding a joint? Sprain Dislocation Subluxation Strain
Sprain
A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: pleural effusion. pulmonary edema. atelectasis. oxygen toxicity.
atelectasis.
A client sustains an open fracture of the left arm after an accident. What does emergency management of this fracture involve? Select all that apply. covering the area with a sterile dressing if the fracture is open immobilizing the affected site splinting the injured limb asking the client if they are able to move the arm wrapping the arm in an ace bandage
covering the area with a sterile dressing if the fracture is open immobilizing the affected site splinting the injured limb
The classification of Stage II of COPD is defined as at risk for COPD. moderate COPD. severe COPD. very severe COPD. mild COPD.
moderate COPD.
The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the client indicates the need for further instruction? "Because I am prescribed a corticosteroid-containing MDI, I will rinse my mouth with water after use." "I can't use a spacer or holding chamber with the MDI." "I will take a slow, deep breath in after pushing down on the MDI." "I will shake the MDI container before I use it."
"I can't use a spacer or holding chamber with the MDI."
A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching? "I will avoid friends and family members who are sick." "I will eat lots of chicken and dairy products." "I may stop taking this medication when I feel better." "I will see my ophthalmologist regularly for a check-up."
"I may stop taking this medication when I feel better."
The 56 year old client diagnosed with tuberculosis is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? "I will take my medication for the full 3 weeks prescribed." "I must stay on the medication for months if I am to get well." "I can be around my friends because I have started taking antibiotics." "I should get a TB skin test every 3 months to determine if I am well."
"I must stay on the medication for months if I am to get well."
A client seeks medical attention for new onset of weight loss and heat intolerance. Which additional statements indicate to the nurse that the client is experiencing hyperthyroidism? Select all that apply. "I always carry an extra sweater with me since I'm always cold no matter the temperature outside." "I use lotion on my skin 2 to 3 times a day since my skin is so dry and itchy." "I switched from knitting to glue projects since I have developed tremors in my hands." "Even sitting still, sometimes it feels like my heart is racing." "My children tell me that my eyes appear to be bigger, almost buldging, particularly when I tell them to do the dishes."
"I switched from knitting to glue projects since I have developed tremors in my hands." "Even sitting still, sometimes it feels like my heart is racing." "My children tell me that my eyes appear to be bigger, almost buldging, particularly when I tell them to do the dishes."
A nurse is caring for a client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching? "I will take my pain medications according to the schedule we developed." "I will increase my fluid and calcium intake." "I'll schedule a follow-up visit with my physician as soon as I get home." "I'll call my physician if I notice tingling around my lips."
"I will increase my fluid and calcium intake."
A client with hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which instruction is most important for the nurse to include in the client's teaching plan? "Maintain a moderate exercise program." "Rest as much as possible." "Lose weight." "Jog at least 2 miles per day."
"Maintain a moderate exercise program."
A group of students are reviewing information about the relationship between the hypothalamus and the pituitary gland. The students demonstrate the need for additional study when they state: "The pituitary gland, as the master gland, controls the secretion of hormones by the hypothalamus." "The hypothalamus, a portion of the brain between the cerebrum and brain stem, creates a pathway for neurohormones." "Corticotropin-releasing hormone from the hypothalamus triggers ACTH secretion by the pituitary gland." "The hypothalamus secretes releasing hormones that stimulate or inhibit pituitary gland secretions."
"The pituitary gland, as the master gland, controls the secretion of hormones by the hypothalamus."
A nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? "Use your continuous passive motion machine for 2 hours each day." "You need to perform weight-bearing exercises twice a week." "You need to limit the amount of protein and calcium in your diet." "You will receive IV antibiotics for 3 to 6 weeks."
"You will receive IV antibiotics for 3 to 6 weeks."
The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for? An open reduction A fasciotomy A total hip replacement A total knee replacement
A fasciotomy
A client has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this client's immediate care? Select all that apply. Administering diuretics to prevent fluid overload Administering beta blockers to reduce heart rate Administering insulin to reduce blood glucose levels Applying interventions to reduce the client's temperature Administering corticosteroids
Administering beta blockers to reduce heart rate Applying interventions to reduce the client's temperature Administering corticosteroids
The nurse is caring for a patient with hyperparathyroidism and observes a calcium level of 16.2 mg/dL. What interventions does the nurse prepare to provide to reduce the calcium level? Select all that apply. Administration of calcitonin Administration of calcium carbonate Intravenous isotonic saline solution in large quantities Monitoring the patient for fluid overload Administration of a bronchodilator
Administration of calcitonin Intravenous isotonic saline solution in large quantities Monitoring the patient for fluid overload
A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which gland? Adrenal cortex Pancreas Adrenal medulla Parathyroid
Adrenal cortex
A client with chronic lung disease is prescribed chest percussion. For which reason will the nurse question this treatment for the client? Age 75 years Left hip replaced 5 years ago Receiving intravenous fluid therapy Diagnosed with bacterial pneumonia
Age 75 years
A client with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed? Ipratropium bromide Fluticasone propionate Ipratropium bromide and albuterol sulfate Albuterol
Albuterol
What clinical manifestations does the nurse recognize would be associated with a diagnosis of hyperthyroidism? Select all that apply. A pulse rate slower than 90 bpm An elevated systolic blood pressure Muscular fatigability Weight loss. Intolerance to cold
An elevated systolic blood pressure Muscular fatigability Weight loss.
A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis? Anxiety Imbalanced nutrition: More than body requirements Impaired swallowing Unilateral neglect
Anxiety
A client had an above-the-knee amputation of the left leg related to complications from peripheral vascular disease. The nurse enters the client's room and observes the dressing and bed covers saturated with blood. What is the first action by the nurse? Notify the health care provider. Apply a tourniquet. Use skin clips to close the wound. Reinforce the dressing.
Apply a tourniquet.
A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply. Massage Applying ice Compression dressings Resting the affected extremity Corticosteroids Elevating the injured limb
Applying ice Compression dressings Resting the affected extremity Elevating the injured limb
A nurse is caring for a client recovering from a hypophysectomy. What would be included in the client's care plan? Select all that apply. Assess for neurologic changes. Closely monitor nasal packing and postnasal drainage. Encourage deep breathing and coughing. Offer the client a straw when drinking liquids.
Assess for neurologic changes. Closely monitor nasal packing and postnasal drainage.
The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implements first? Notify the client's surgeon immediately. Assess the client's blood pressure and pulse. Reinforce the dressing with additional dressing. Check the client's last hemoglobin and hematocrit levels.
Assess the client's blood pressure and pulse.
Which action would be most important postoperatively for a client who has had a knee or hip replacement? Providing crutches to the client. Assisting in early ambulation. Using a continuous passive motion (CPM) machine. Encouraging expressions of anxiety.
Assisting in early ambulation.
The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction that leads to the collapse of alveoli. This complication is known as Atelectasis Emphysema Pleurisy Pneumonia
Atelectasis
A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect? Infection Pulmonary embolism Avascular necrosis Hypovolemic shock
Avascular necrosis
A group of students are reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast? Better molding to the client Quicker drying Longer-lasting More breathable
Better molding to the client
A patient has stepped in a hole in the yard, causing an ankle injury. The ankle is edematous and painful to palpation. How long should the nurse inform the patient that the acute inflammatory stage will last? Less than 24 hours Between 24 and 48 hours About 72 hours At least 1 week
Between 24 and 48 hours
Which statement is true about both lung transplant and bullectomy? Both procedures cure COPD. Both procedures treat end-stage emphysema. Both procedures treat patients with bullous emphysema. Both procedures improve the overall quality of life of a client with COPD
Both procedures improve the overall quality of life of a client with COPD
Trousseau's sign is elicited by which of the following? Carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff. A sharp tapping over the facial nerve just in front of the parotid gland and anterior to the ear causes spasm or twitching of the mouth, nose, and eye. After making a clenched fist, the palm remains blanched when pressure is placed over the radial artery. The patient complains of pain in the calf when his foot is dorsiflexed
Carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff.
A client with a fractured distal left radius reports discomfort at the cast site, with pain specifically in the upper forearm. What would the nurse expect the physician to do? Cut a cast window. Remove the cast. Apply a fiberglass cast. Initiate physical therapy.
Cut a cast window.
During physical examination of a client with a suspected endocrine disorder, the nurse assesses the body structures. The nurse gathers this data based on the understanding that it is an important aid in which of the following? Detecting evidence of hormone hypersecretion Detecting information about possible tumor growth Determining the presence or absence of testosterone levels Determining the size of the organs and location
Detecting evidence of hormone hypersecretion
The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report the health care provider immediately? Localized edema and discoloration occurring hours after the injury. Generalized weakness and increasing sensitivity to touch. Dorsalis pedis pulse cannot be located with a doppler and increasing pain. Pain relieved after taking 4 mg of hydromorphone, a narcotic analgesic.
Dorsalis pedis pulse cannot be located with a doppler and increasing pain.
The nurse teaching the client with a cast about home care includes which instruction? Cover the cast with plastic or rubber Keep the cast below heart level Fix a broken cast by applying tape Dry a wet fiberglass cast thoroughly to avoid skin problems
Dry a wet fiberglass cast thoroughly to avoid skin problems
A nurse is caring for a client who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.) Encouraging the client to care for the residual limb Allowing the client to express grief Encouraging the client to have family and friends view the residual limb to decrease self-consciousness Encouraging family and friends to refrain from visiting temporarily because this may increase the client's embarrassment Introducing the client to local amputee support groups
Encouraging the client to care for the residual limb Allowing the client to express grief Introducing the client to local amputee support groups
The nurse has instructed the client to use a peak flow meter. The nurse evaluates client learning as satisfactory when the client Exhales hard and fast with a single blow Inhales deeply and holds the breath Records in a diary the number achieved after one breath Sits in a straight-back chair and leans forward
Exhales hard and fast with a single blow
A client with a fractured ankle is having a fiberglass cast applied. The client starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate? Explain that the sensation being felt is normal and will not burn the client. Remove the cast immediately, notifying the physician. Administer antianxiety and pain medication. Call for assistance to hold the client in the required position until the cast has dried.
Explain that the sensation being felt is normal and will not burn the client.
A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication? Avascular necrosis of bone Compartment syndrome Fat embolism syndrome Complex regional pain syndrome
Fat embolism syndrome
The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing: Complex regional pain syndrome Delayed union Compartment syndrome Fat embolism syndrome
Fat embolism syndrome
The nurse is caring for a client diagnosed with hypothyroidism secondary to Hashimoto thyroiditis. When assessing this client, what sign or symptom would the nurse expect? Fatigue Bulging eyes Palpitations Flushed skin
Fatigue
The femur fracture that commonly leads to avascular necrosis or nonunion because of an abundant supply of blood vessels in the area is a fracture of the: Condylar area. Femoral neck. Shaft of the femur. Trochanteric region.
Femoral neck.
A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect: thyroiditis. Graves' disease. Hashimoto's thyroiditis. multinodular goiter.
Graves' disease.
Which of the following precautions would be most appropriate when caring for a client being treated with radioactive iodine (RAI) for a thyroid tumor? Administer prescribed corticosteroids carefully. Handle body fluids carefully. Monitor the respiratory status. Administer the prescribed medications at the same time each day.
Handle body fluids carefully.
A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign? Have the patient extend both hands while the nurse compares the volume of both radial pulses. Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. Have the patient plantar flex both feet while the nurse performs the blanch test on all of the patient's toes. Have the patient squeeze the nurse's hands with his or her hands to evaluate any difference in strength.
Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg.
A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client? Full-liquid High protein 1,800-calorie ADA Low-fat
High protein
The nurse is assessing a client in the clinic who appears restless, excitable, and agitated. The nurse observes that the client has exophthalmos and neck swelling. What diagnosis do these clinical manifestations correlate with? Hypothyroidism Hyperthyroidism Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Diabetes insipidus (DI)
Hyperthyroidism
A client diagnosed with meningitis says, "I'm just so thirsty. I keep drinking and drinking but I just can't seem to get enough. I've been urinating a lot, too." The nurse checks the client's urine specific gravity and finds it to be very dilute. The nurse suspects that the client may be developing diabetes insipidus. Which assessment finding would support the nurse's suspicion? Select all that apply. Weight gain Decreased heart rate Hypotension Poor skin turgor Dry mucous membranes
Hypotension Poor skin turgor Dry mucous membranes
A client has been diagnosed with myxedema from long-standing hypothyroidism. What clinical manifestations of this disorder does the nurse recognize are progressing to myxedema coma? Select all that apply. Hypothermia Hypertension Hypotension Hypoventilation Hyperventilation
Hypothermia Hypotension Hypoventilation
The nurse is caring for a patient with Graves disease. Which characteristics support this diagnosis? Fatigue, weight loss, and renal stones Buffalo hump, hirsutism, hyperglycemia Hypoglycemia, bronze skin, fatigue Increased appetite, weight loss, tachycardia
Increased appetite, weight loss, tachycardia
Which nursing diagnosis takes highest priority for a client with a compound fracture? Imbalanced nutrition: Less than body requirements related to immobility Impaired physical mobility related to trauma Infection related to effects of trauma Activity intolerance related to weight-bearing limitations
Infection related to effects of trauma
Which of the following is the key underlying feature of asthma? Inflammation Shortness of breath Productive cough Chest tightness
Inflammation
The nurse knows to assess a patient with hyperthyroidism for the primary indicator of: Fatigue Weight gain Constipation Intolerance to heat
Intolerance to heat
A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement? Maintain bed rest with the head of the bed at 20 degrees. Withhold opioid pain medication to prevent ileus. Maintain NPO (nothing by mouth) status for surgical repair. Sit the client upright in a padded chair for meals.
Maintain bed rest with the head of the bed at 20 degrees.
A client with a fractured femur is in balanced suspension traction. The client needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? Place slight additional tension on the traction cords. Release the weights and replace them immediately after positioning. Reposition the bed instead of repositioning the client. Maintain consistent traction tension while repositioning
Maintain consistent traction tension while repositioning
Which intervention is the most critical for a client with myxedema coma? Administering an oral dose of levothyroxine (Synthroid) Warming the client with a warming blanket Measuring and recording accurate intake and output Maintaining a patent airway
Maintaining a patent airway
For a client with Graves' disease, which nursing intervention promotes comfort? Restricting intake of oral fluids Placing extra blankets on the client's bed Limiting intake of high-carbohydrate foods Maintaining room temperature in the low-normal range
Maintaining room temperature in the low-normal range
A client is recovering from a below-the-knee traumatic amputation and is 72 hours post surgery. Which actions will the nurse take to promote healing of the wound? Select all that apply. Measure the residual limb every 8 to 12 hours. Elevate the residual limb on a pillow when seated. Assess neurovascular function of the residual limb. Apply an elastic compression bandage over the wound site. Remind to place the residual limb in a dependent position when sitting.
Measure the residual limb every 8 to 12 hours. Assess neurovascular function of the residual limb. Apply an elastic compression bandage over the wound site.
The nurse assesses a client after total right hip arthroplasty and observes a shortening of the extremity. The client reports severe pain in the right side of the groin. What is the priority action of the nurse? Apply Buck's traction. Notify the health care provider. Externally rotate the extremity. Bend the knee and rotate the knee internally.
Notify the health care provider.
A nurse is admitting a client to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the client may have a peroneal nerve injury? Numbness and burning of the foot Pallor to the dorsal surface of the foot Visible cyanosis in the toes Inadequate capillary refill to the toes
Numbness and burning of the foot
The nurse is assessing the client diagnosed with COPD. Which data requires immediate intervention by the nurse? Large amounts of thick white sputum. Oxygen flow meter set on 8 liters. Use of accessory muscles during inspiration. Presence of a barrel chest and dyspnea.
Oxygen flow meter set on 8 liters.
A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments? Oxygen through nasal cannula at 2 L/minute Intravenous methylprednisolone (Solu-Medrol) 120 mg Ipratropium bromide (Alupent) by metered-dose inhaler Vancomycin 1 gram intravenously over 1 hour
Oxygen through nasal cannula at 2 L/minute
The nurse is preparing a client for a thyroid test. Which medications that the client is taking should be documented on the laboratory slip as possibly affecting the thyroid test? Select all that apply Phenytoin Metoclopramide Lisinopril Furosemide Amphetamine
Phenytoin Metoclopramide Furosemide Amphetamine
The nurse is caring for a client with hypoparathyroidism. When the nurse taps the client's facial nerve, the client's mouth twitches and the jaw tightens. What is this response documented as related to the low calcium levels? Positive Chvostek's sign Positive Trousseau's sign Positive paresthesias Positive Babinski's sign
Positive Chvostek's sign
A client with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply. Elevate the arm above the heart. Prepare to remove the cast. Provide support to the injured extremity. Assess neurovascular status every 8 hours. Apply ice to extremity.
Prepare to remove the cast. Provide support to the injured extremity.
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? Presence of Trousseau sign Slurred speech Negative Chvostek sign Muscle weakness
Presence of Trousseau sign
The nurse is caring for a client who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? Keep the affected leg in a position of adduction. Have the client reposition himself independently. Protect the affected leg from internal rotation. Keep the hip flexed by placing pillows under the client's knee.
Protect the affected leg from internal rotation.
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? Increased amount of fiber in the diet. Encourage a low calorie, low protein diet. Decrease the clients fluid intake to 1000 ML/day. Provide six small, well balanced meals a day.
Provide six small, well balanced meals a day.
The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for? Atelectasis Hypovolemia Pulmonary embolism Urinary tract infection
Pulmonary embolism
As status asthmaticus worsens, the nurse would expect which acid-base imbalance? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis
Respiratory acidosis
In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances? Respiratory acidosis Respiratory alkalosis Metabolic alkalosis Metabolic acidosis
Respiratory acidosis
The nurse is planning the care of a client diagnosed with SIADH. Which interventions should be implemented? Select all that apply. Restrict fluids per health care provider order. Assess LOC every 2 hours. Provide an atmosphere of stimulation. Monitor urine and serum osmolality. Weigh the client every 3 days.
Restrict fluids per health care provider order. Assess LOC every 2 hours. Monitor urine and serum osmolality.
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? Infusing IV fluids rapidly as ordered Encouraging increased oral intake Restricting fluids Administering glucose-containing I.V. fluids as ordered
Restricting fluids
A nurse is planning the care of a client who will require a prolonged course of skeletal traction. When planning this client's care, the nurse should prioritize interventions related to what risk nursing diagnosis? Risk for Impaired Skin Integrity Risk for Falls Risk for Imbalanced Fluid Volume Risk for Aspiration
Risk for Impaired Skin Integrity
The nurse is preparing the preoperative client, for a total hip replacement. Which intervention should the nurse implement postoperatively? Keep an abduction pillow in place between the legs at all times. Cough and deep breathe at least every 4 to 5 hours. Turn to both sides every 2 hours to prevent pressure ulcers. Sit in a high-seated chair for a flexion of less than 90 degrees.
Sit in a high-seated chair for a flexion of less than 90 degrees.
The nurse is planning the care of a client with hyperthyroidism. What should the nurse specify in the client's meal plan? A reduced calorie diet, high in nutrients Small, frequent meals, high in protein and calories Three large, bland meals a day A diet high in fiber and plant-sourced fat
Small, frequent meals, high in protein and calories
Which device is designed specifically to initially support and immobilize a body part in a desired position until swelling subsides? Brace Continuous passive motion (CPM) device Splint Trapeze
Splint
The client diagnosed with Addison's disease is admitted to the emergency department after a day at the Lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? Start an IV with an 18 gauge needle and infuse NS rapidly. Have the client wait in the waiting room until about is available. Obtain a permit for the client to receive a blood transfusion. Collect a urinalysis and blood sample for a CBC and calcium level.
Start an IV with an 18 gauge needle and infuse NS rapidly.
A client has a decreased level of thyroid hormone being excreted. What will the feedback loop do to maintain the level of thyroid hormone required to maintain homeostatic stability? Stimulate more hormones using the negative feedback system Stimulate more hormones using the positive feedback system Produce a new hormone to try and regulate the thyroid function Be unable to perform in response to low levels of thyroid hormone.
Stimulate more hormones using the negative feedback system
A client comes to the emergency department and it is found that the client's radial head is partially dislocated. What is this partially dislocated radial head documented as? Volkmann's contracture Subluxation Compartment syndrome Sprain
Subluxation
Dilutional hyponatremia occurs in which disorder? Diabetes insipidus (DI) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Pheochromocytoma Addison disease
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
The nurse is teaching a client that the body needs iodine for the thyroid to function. What is the function of iodine? Maintaining body metabolism in a steady state Maintaining effective oxygen consumption Synthesis of thyroid hormones Altering the responsiveness of body tissue to other hormones
Synthesis of thyroid hormones
A nurse is teaching the client about use of a spacer with a metered-dose inhaler (MDI). What instructions should the nurse include in the teaching? Select all that apply. Take a slow, deep inhalation from the device. Use normal inhalations with the device. Activate the MDI once. The device may increase delivery of the MDI medication. It is not necessary to hold your breath after using.
Take a slow, deep inhalation from the device. Activate the MDI once. The device may increase delivery of the MDI medication.
The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? Notify the health care provider to have chest tube reinserted stat. Instruct the client to take slow shallow breaths until the tube is reinserted. Take no action and assess the clients respiratory status every 15 minutes. Tape a petroleum jelly occlusive dressing on 3 sides to the insertion site.
Tape a petroleum jelly occlusive dressing on 3 sides to the insertion site.
The nurse is admitting a client to the neuro intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrants immediate intervention? The client is alert to name but is unable to tell the nurse the location. The client has an output of 2500 ML since surgery and an intake of 1000 ML. The clients vital signs are T 97.6, P 88, R 20, and BP 130/80. The client has a 3cm amount of dark red drainage on the turban dressing.
The client has an output of 2500 ML since surgery and an intake of 1000 ML.
For which of the following immobility-related complications is the client in traction at risk? Select all that apply. Cachexia Thromboemboli Urinary stasis Diarrhea Lactose intolerance
Thromboemboli Urinary stasis
Early this morning, a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client (who now has nausea) and records a temperature of 105°F (40.5°C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? Diabetic ketoacidosis Thyroid crisis Hypoglycemia Tetany
Thyroid crisis
A nurse is caring for a client in skin traction. In order to prevent bony fragments from moving against one another, the nurse should caution the client against performing what action? Shifting one's weight in bed Bearing down while having a bowel movement Turning from side to side Coughing without splinting
Turning from side to side
The nurse is caring for a client 6 hours postoperative right total knee replacement. Which data should the nurse report to the surgeon? A total of 30 mLs of red drainage in the JP drain. Pain relief after using the PCA pump. Cool toes, distal pulses palpable, and pale nail beds bilaterally. Urinary output of 60 mLs of clear yellow urine in 3 hours.
Urinary output of 60 mLs of clear yellow urine in 3 hours.
Which hormones are secreted by the posterior lobe of the pituitary gland? Select all that apply. Vasopressin Oxytocin Thyroid-stimulating hormone (TSH) Follicle-stimulating hormone (FSH) Luteinizing hormone (LH)
Vasopressin Oxytocin
A patient falls while skiing and sustains a supracondylar fracture. What does the nurse know is the most serious complication of a supracondylar fracture of the humerus? Hemarthrosis Paresthesia Malunion Volkmann's ischemic contracture
Volkmann's ischemic contracture
A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect? Weight gain, constipation, and lethargy Weight loss, nervousness, and tachycardia Exophthalmos, diarrhea, and cold intolerance Diaphoresis, fever, and decreased sweating
Weight loss, nervousness, and tachycardia
When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect: a blood pressure of 130/70 mm Hg. a blood glucose level of 130 mg/dl. bradycardia. a blood pressure of 176/88 mm Hg.
a blood pressure of 176/88 mm Hg.
A nurse is caring for a client with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which finding would indicate that the client has developed fluid overload? dyspnea and hypertension pulmonary congestion and muscle cramps confusion and diarrhea hypertension and weight gain without edema
dyspnea and hypertension
When instructing a client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of: restricting fluids. restricting sodium. encouraging fluids. restricting potassium.
encouraging fluids.
A client has been experiencing a decrease in serum calcium. After diagnostics, the physician proposes the calcium level fluctuation is due to altered parathyroid function. What is the typical number of parathyroid glands? four three two one
four
Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction experiences: heat intolerance and systolic hypertension. weight gain and heat intolerance. diastolic hypertension and widened pulse pressure. anorexia and hyperexcitability.
heat intolerance and systolic hypertension.
A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: instruct the client to drink at least 2 L of fluid daily. maintain the client on bed rest. administer anxiolytics, as ordered, to control anxiety. administer pain medication as ordered.
instruct the client to drink at least 2 L of fluid daily.
A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? osteomyelitis hematoma hemorrhage infection
osteomyelitis
A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of: severe hypotension. excessive thirst. profound neuromuscular irritability. acute gastritis.
profound neuromuscular irritability.
A nurse is caring for a client with a kidney disorder. What hormone released by the kidneys initiates the production of angiotensin and aldosterone to increase blood pressure and blood volume? renin erythropoietin cholecystokinin gastrin
renin
The classification of Stage III of COPD is defined as at risk for COPD. mild COPD. severe COPD. very severe COPD. moderate COPD.
severe COPD.
A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of: calcium and phosphorus abnormalities. chloride and magnesium abnormalities. sodium and chloride abnormalities. sodium and potassium abnormalities.
sodium and potassium abnormalities.
